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Judith Lumley Centre Under the pump: the Mothers and Infants Lactation Cohort (MILC) study Helene Johns, Della Forster, Lisa Amir, Helen McLachlan, Anita Moorhead, Rachael Ford, Kerri McEgan latrobe.edu.au CRICOS Provider 00115M La Trobe University 1

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Background Increasing reports of women giving expressed breast milk (EBM) rather than directly feeding from breast • Australia – rate of expressing almost doubled in decade to 2002 (Binns et al 2006) • US - 73% of women expressed at least once in first six months (Geraghty et al 2005) • Singapore – rate of exclusive expressing doubled to 18% in seven years to 2008 (Hornbeak et al 2010) • Reasons for increase poorly understood → more evidence needed (Geraghty et al 2005) La Trobe University 3

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What is known? Lack of evidence on the association between feeding EBM and breastfeeding duration Outcomes of breast milk expression are unknown:  Maternal → mastitis? fatigue? stress? anxiety? respite? freedom?  Infant → bonding? self regulation? orofacial development? La Trobe University 6

Potential risks of not breastfeeding at the breast ↓ Vitamin content (Hanna 2004) ↓ Self-regulation of intake (Li 2010) ↑ Risk of childhood obesity (Li 2012) ↑ Dental caries (Harris 2004) ↑ Orthodontic problems associated with not breastfeeding (Emerich 2010) ↑ Adverse reactions related to pump use (Clemons 2010) Compromised milk quality and safety ( Boo 2001, Geraghty 2010) La Trobe University 7

Study design Prospective cohort study (MILC – Mothers and Infants Lactation Cohort) Hypothesis: “Infants fed solely at the breast in the 24 to 48 hours after birth are more likely to be breastfeeding at six months than other infants” La Trobe University 8

The Mothers and Infants Lactation Cohort (MILC) Study Aims To explore:  the prevalence and outcomes of breast milk expression  whether feeding other than directly from the breast prior to hospital discharge decreases the proportion of infants receiving any breast milk at six months La Trobe University 9

Participants Women recruited from three Melbourne maternity hospitals 24-48 hours postpartum  Mercy Hospital for Women  Royal Women’s Hospital  Frances Perry House Eligibility criteria  feeding some breast milk  singleton infant born at term (≥37 weeks)  English-speaking Excluded if either the mother or infant very ill La Trobe University 10

Outcome measures Primary outcome: • any breast milk feeding at six months Secondary outcomes: • exclusive breastfeeding duration • breastfeeding at three months • expressing outcomes (frequency, duration, amount, method) • maternal mental health • breastfeeding confidence and satisfaction Other descriptive data collected: • background demographic data/maternal BMI/maternal smoking/method of birth La Trobe University 11

Data collection Data collected at three time points In hospital after the birth • structured interview (demographic details, breastfeeding intentions, current feeding details) • obstetric data medical record 3 months postpartum – structured telephone interview (data not presented here) 6 months postpartum – structured telephone interview • Some open-ended questions at each time point to allow for extra comments by women La Trobe University 12

Sample size Used Victoria’s 2009 state average of ‘any’ breastfeeding at 6 months postpartum: 46% To detect a 10% difference in either direction (i.e. 46%→56% or 36%) → needed a total of 822 women → to allow for loss to follow up planned to recruit 1000 women La Trobe University 13

Study participation Recruitment July 2009 – April 2011 499 Primipara / 504 Multipara Total = 1003 3 month interview (telephone) Discontinued 560/888 (63%) April 2011 6 month interview (telephone) 924/1003 (92%) La Trobe University 14

Snapshot of findings Study participant characteristics Infant feeding at recruitment and six months Expressing patterns and breast pump usage La Trobe University 15

The Mothers and Infants Lactation Cohort (MILC) Study Main study outcomes • Only 36% of healthy term infants of primiparous women and 61% of those born to multipara were exclusively breastfed at the breast in the first 24-48 hours ( Johns et al Acta Paediatrica 2013) • Women feeding only directly at the breast in the first 24-48 hours (compared with any other feeding combination) were more likely to be continuing to be breast milk feeding at 6 months (Forster et al BMC Pregnancy & Childbirth 2015) La Trobe University 16

Participant characteristics Characteristic (n = 1003) (unless otherwise stated) n % Click here to enter Title Click here to enter Text Primiparous 499 49.8 Click here to enter Text Married/Living with partner 971 96.8 Click here to enter Text Education (diploma/degree) 727 72.5 Click here to enter Text Public hospital care 667 66.5 Smoking prior to pregnancy 127 12.7 Plan to breastfeed ≥ 6 months 817 85.6 (n=954) English first language 692 69.0 Australian-born (n=1002) 674 67.3 La Trobe University 17

Reasons for not feeding at the breast (in hospital) Reason n %* (* able to give more than one response) (n=518) Advice from doctor/midwife 216 41.7 Click here to enter Title Attaching/sucking difficulties 180 34.8 Click here to enter Text Baby sleepy 82 15.8 Click here to enter Text Click here to enter Text Not enough milk 62 12.0 Click here to enter Text Nipple pain/trauma 33 6.4 Low baby blood sugar levels 24 4.6 Staff concern about infant weight loss 20 3.9 Mother unwell 18 3.5 Breasts too full 10 1.9 Personal preference 1 0.2 Baby premature 1 0.2 Not enough help breastfeeding 1 0.2 La Trobe University 19

Feeding in the first 24-48 hours Feeding Primipara Multipara All (EBM = expressed (n=499) (n=504) (n=1003) breast milk) Click here to enter Title n % n % n % Click here to enter Text Click here to enter Text Feeding only at 177 35.5 308 61.1 485 48.4 Click here to enter Text breast Click here to enter Text Breast + EBM 187 37.5 105 20.8 292 29.1 Breast, EBM + 104 20.8 57 11.3 161 16.1 formula Breast + formula 21 4.2 32 6.4 53 5.3 EBM only 5 1.0 1 0.2 6 0.6 EBM + formula 4 0.8 1 0.2 5 0.5 Fully formula 1 0.2 0 0 1 0.1 feeding La Trobe University 20

Summary: at 24 - 48 hours of age: 48% fully breastfeeding at the breast since birth - primipara and those not confident with breastfeeding less likely - women confident about supply and those intending to breastfeed six months or more – more likely • 47% had received some expressed breast milk • 23% had received some artificial formula • 16% considered their milk supply inadequate • 30% reported problems with feeding La Trobe University 23

Feeding any breast milk at 6 months Time since Primipara Multipara All Click here to enter Title birth Click here to enter Text n % n % n % Click here to enter Text Click here to enter Text Six months 298/456 65.4 316/456 69.3 615/913 67.4 Click here to enter Text La Trobe University 24

Relationship between feeding method in hospital and giving any breast milk at 6 months Feeding in hospital Primipara Multipara All first 24 -48 hours (n=457) (n=457) (n=914) Click here to enter Title Click here to enter Text n % n % n (%) % Click here to enter Text Click here to enter Text Directly at breast Click here to enter Text only 123/161 76.4 215/283 76.0 338/444 76.1 Had some EBM 167/276 60.5 88/145 60.7 255/421 60.6 Had at least some EBM and formula 47/95 49.5 34/49 69.4 81/144 56.3 Had some formula 55/114 48.3 47/77 61.0 102/191 53.4 La Trobe University 25

Feeding from the breast directly in hospital compared with any other type of feeding: … association with any breast milk at 6 months Click here to enter Title Any breast Direct only Any other AjOR (95% CI)* Click here to enter Text milk feeding Click here to enter Text Click here to enter Text n % n % Click here to enter Text Any breast 338/444 76.1 276/468 59.0 1.8 (1.28, 2.51) milk 6 mths * adjusted for parity, type of birth, breastfeeding intention, perceived breastfeeding problems at recruitment, public private status and education La Trobe University 26

Summary: feeding outcomes Feeding other than directly at the breast in hospital associated with decreased breast milk feeding at 6 months Infants receiving any formula in hospital least likely to receive any breast milk at 6 months La Trobe University 27

Breast pump ownership at birth (all women) Click here to enter Title Primipara Multipara All Click here to enter Text Click here to enter Text (n=457) (n=457) (n=914) Click here to enter Text Click here to enter Text n % n % n % 224 49.0 334 73.1 558 61.0 La Trobe University 28

Who suggested pump (primiparous women only) n % * Click here to enter Title Suggested pump Click here to enter Text (n=239) Click here to enter Text Self 107 44.8 Click here to enter Text Friends / partner / family 103 43.1 Click here to enter Text Gift 40 16.8 Midwife / Lactation Consultant 20 8.4 Other 4 1.7 *Women could give more than one answer La Trobe University 29